When the World Health Organisation (WHO) dedicated Year 2020 as “The Year of the Nurse and the Midwife”, nobody thought it would coincide with a global pandemic, putting the health sector at the forefront of the battle. That campaign was actually following a three-year Nursing Now! campaign aiming to raise awareness of the profile and status of nurses worldwide, and the urgent need to improve their employment conditions. As all of us can imagine, Covid-19 pandemic has brought that message to the fore, including the importance of preventing violence and harassment in the world of work.

The Covid‑19 has made the challenges in health work visible to the society at large and exacerbated a hazard widespread in the healthcare sector: violence and harassment. Attacks on nursing workforce are reported from all corners of the world and within all types of health and care settings. Howard Catton, CEO of International Council of Nurses (ICN) underlined this in May 2020 by saying that nurses are in a high‑risk situation, especially those working in close proximity to patients with Covid‑19 without adequate personal protective equipment (PPE). But the fact that workers fear physical attacks and abuse on their journeys to and from work or simply at work is completely unacceptable.

When we look at the latest reports published by the International Labour Organisation (ILO) on Covid‑19, we can read that the exposure of healthcare workers to discrimination, stigma, violence, and harassment has increased all over the world. Across India, for example, reports describe health‑care workers being beaten, stoned, threatened, and evicted from their homes2. In Australia and Canada nurses have been spat on in public transport. In Mexico, nurses and doctors have been banned from public transportation and verbally attacked; a nurse and a doctor were doused in bleach. In Swaziland, women healthcare workers have reported being asked for sexual favours in return for personal protective equipment.

Nursing is the largest occupational group in the health sector, accounting for six out of ten of the health professions, and the workforce is predominantly women. Regional variations range from 75 % in Africa, 89 % in south‑east Asia and Europe, to 95 % in the Western Pacific nurses being women.“In this period of pandemic, a bad situation has become worse”, explains Baba Aye, Health and Social Sector Officer at the Public Services International (PSI).

“You find violence in the workplace, but also increasingly outside the workplace; in public transport, on the streets... Public’s fear of infection – often fed by fake news, has resulted in nurses and doctors having been beaten, pelted with stones, and spat at; some landlords have asked nurses to leave their homes, and there were demonstrations against health workers in Ukraine demanding them to move to the outskirts of a city. In Mexico, there have been 50 attacks documented against health workers, and 265 cases of discrimination. There has been record of community health workers in India facing sexual harassment, including rape, when doing contact tracing in the field. Health workers face discrimination from patients, and from the families of patients who have been put in isolation or who have died from corona virus, who take laws into their own hands and get violent.”

Marie Clarke Walker, Secretary Treasurer at the Canadian Labour Congress thinks that Covid‑19 should actually be considered as a double pandemic: “it’s about dealing with Covid‑19 and also dealing with the impact of racism. And that racism is both overt and covert, so systemic and an in your face. It’s racism, discrimination, and violence all wrapped up. You hear the stories of people saying to care workers, “Oh no, I don’t want you to touch me ‘cause you’re black!” This impacts the workers and is a form of psychological harm.” In Canada, more than one third of nurse aides, hospital and patient service associates are women with migrant backgrounds; racialized women make up 13 % of the total workforce, but 25 % of workers in nursing and residential care facilities and 27 % of workers in home health‑care services4. In UK, the Royal College of Nursing (RCN) has raised serious concerns about racism in the National Health Services.

Another aspect of violence against health workers is the violence from the state – whether direct or economic. Baba Aye knows that workers’ rights in several countries (US, France, Kenya, Nigeria) have been violated for organising demonstrations to demand workplace safety and personal protective equipment. In Zimbabwe, 13 nurses and union representatives were arrested on 6 July 2020 and detained by the police for demanding improved workplace safety and social dialogue for improved wages. “The Minister of Health promised to look into their issues regarding wages, allowances and PPE, but we have not seen openings for the new pay and benefits for nurses yet, so that promise is to be fulfilled”, explains Fiona Gandiwa Magaya, the Coordinator of the Gender Department for the Zimbabwe Congress of Trade Unions (ZCTU).

The initial response to violence and harassment has been that of condemnation by international organisations and trade unions. The immediate practical measures have been diverse ‑ Chinese healthcare workers were taught self‑defence, and authorities in Sudan created a police force to protect health workers and facilities, prompted by a threat of a strike action from doctors across the country. In New South Wales, Australia, nurses issued a plea to their local communities: “help us to help you”. Nagkaisa!, the broadest coalition of labour groups in the Philippines, highlighted that violence, abuse and discrimination against healthcare workers during Covid‑19 are not ordinary breach of law but violations of human rights. “There needs to be immediate strict measures put in place to protect healthcare workers, such as laws and regulations with penalties, and practical issues such as dedicated transport for healthcare workers in particular cities where attacks have happened, and accommodation”, outlines Baba Aye. For longer‑term solutions, the call is out by trade unions for the governments to ratify the ILO Convention on Eliminating Violence and Harassment in the World of Work (C190).

Eliminating Violence and Harassment in the World of Work 

The landmark ILO Convention 190 and the accompanying Recommendation 206 were adopted in June 2019. It is the first‑ever global treaty on violence and harassment in the world of work.The legally binding Convention sets out the basic principles and rights at work regarding this issue and the Recommendation serves as the guideline. The instruments place clear responsibilities on employers and governments to tackle violence and harassment, including supporting victims of domestic violence. The Convention expands the concept of ‘the world of work’ beyond the immediate physical workplace, accounting thereby, for example commuting to and from work. It also demands that violence by third parties, such as patients, customers or members of public must be addressed. “The Convention defines violence and harassment as a range of unacceptable behaviours and practices that aim at, result in, or are likely to result in physical, psychological, sexual or economic harm”. It covers everyone who works, including interns or apprentices and persons who exercise the duties or authority of an employer, and applies to the public and private sectors, the formal and informal economy, as well as urban and rural areas.

“These strong instruments are the result of trade union activism. Without it, they just would not have ever happened”, stresses Chidi King, Director of the International Trade Union Confederation (ITUC) Equality Department. She was involved in the intensive negotiations and lobbying that led to the adoption of the instruments, and notes that it took four years of hard work. The discussions started around gender equality and decent work, and it was evident that if you talk about decent work you must look at the pervasive issue of violence and harassment in the world of work. Previously, trade unions had been campaigning on issues related to sexual harassment and knew that violence against women is one of the strong barriers to achieving gender equality and decent work. All the research showed serious gaps at national level legislation, and globally, occupational health and safety measures were very patchy. “It was obvious that we needed a Convention setting minimum standards for governments, employers, and trade unions to work towards. The trade union movement ensured, that the instruments include all the structural issues related to violence, such as gender norms that surround the unequal power relations, and economic violence”, Chidi King clarifies.Psychosocial risks at work are addressed in the instruments that provide guidance in terms of both preventing and addressing violence and harassment. “There was an understanding very early on of the importance of getting trade union leadership behind this agenda, and we saw general secretaries, for instance, coming out and speaking to the importance of these instruments. Violence and harassment affect everybody because it goes to the culture in the workplace, and to everybody’s working conditions. Bringing that message along has been very important to trade unions”, explains Chidi King.

“Everything in the Convention applies during Covid”

If anyone was in doubt of the relevance of the Convention and the Recommendation, they have proved their extreme importance during the Covid‑19 pandemic. “I don’t think that anybody thought when we were negotiating the convention and recommendation that we would need to rely on it so soon even though it hadn’t been ratified. Everything in the Convention applies during Covid, the impact on women was severe, gender‑based violence, and domestic violence definitely increased as for most people experiencing domestic violence, so the workplace can be the safest place. Therefore, during lockdowns, staying home put many women directly in harms way. The pandemic also pushed workers who were not usually in the spotlight, into focus, as key frontline and essential workers and shone that bright light on the inequities that were being experienced by vulnerable workers and groups in situations of vulnerability. For the most part, frontline workers were women and all the marginalized groups – informal, migrant or racialized workers. For many of us who were in the ILC [International Labour Conference] negotiating room, this was our everyday reality before the Covid‑19 pandemic, but I don’t think that people really understood the situation of these workers, before it became everyone’s reality”, adds Marie Claire Walker.

The instruments’ call on measures to be taken against third‑party violence is extremely relevant for occupational safety and health during and beyond the pandemic. For example, the convention refers to commute to and from work and it has been essential to get employers and governments to think around the logistics of getting those key workers to and from work safely. Yvonne Oldfield, Deputy Secretary of the New Zealand Secondary Teachers Union (PPTA Te Wehengarua), notes that, “prior to the pandemic, we certainly saw that this Convention was going to be very useful in the care sector. One of the areas in the convention is gender‑based violence from third parties, which is experienced by nurses and teachers, for example, and for which prompt prevention mechanisms need to be further developed. Another example is that the preventative measures should go beyond the actual physical workplace, and include the commuting to and from work, which is relevant for nurses who often work shifts and leave the workplace at nights. Trade unions had reported incidents of nurses having been attacked on the way to or after their work.”

Before the pandemic hit there were many countries in the process of ratification, but the novel coronavirus has slowed down these processes. Fiji, Uruguay and Argentina have now ratified the Convention, and it comes into force on 25 June 2021.

Maria Emeninta, member of the national equality committee at KSBSI union explains that currently, a coalition of 58 organisations, including trade unions, non‑governmental, and community organisations are campaigning to ratify the Convention in Indonesia. They have also collected and analysed sectoral survey data on violence and harassment at work to support the advocacy towards the parliament. In New Zealand, the trade union movement has not had much success in engaging the government on the issue of ratifying the ILO C190.

Yvonne Oldfield tells that the existing health and safety laws, employment legislation, and human rights legislation provide some tools to address violence and harassment at work. However, “we would welcome more traction on this issue, as the Convention could be used to review, overhaul and update the legislation, which is not as effective or nuanced as the Convention which covers issues around gender and sexuality and intersecting inequalities.”In Canada, the government has had roundtables with the provincial and territorial governments, where Marie Clarke Walker and the employer representative have been invited to talk about the importance of C190. “The tripartite group is solid in terms of wanting this ratified and wanting it ratified quickly”, Marie shares the good news.

Temporary paid sick leaves and pandemic pay started to be removed

The Convention is inclusive and formed in the leaving no‑one behind ethos of the UN Sustainable Development Goals (SDG). By taking a broader view of the world of work, beyond the specifics of the workplace, and on how the world of work connects to the broader society, it paves the way to put in place the necessary policies and measures for the post‑Covid world of world.

“From the beginning it was our objective to ‘leave no one behind’. We pushed hard to ensure that everyone was included in this convention. During Covid‑19, and now that we’re dealing with and talking about post‑Covid, it is obvious that this is what was needed”, explains Marie Clarke Walker. However, she also warns that as soon as the pandemic started to slow down in Canada, the support measures, such as 24‑hour childcare for frontline workers, paid sick leaves and pandemic pay started to be removed. “So, society is saying to these workers that you were essential during the peak time, and now we’re going to relegate you right back to where you were before. We cannot go back to what was considered normal. We need to step this up so that those mitigating measures that were put in place become the norm.”

Governments across the globe need to take a hard‑look on the care economy and recognise the importance of it. “Given the fact that it’s women who are responsible for almost all of the care – formal and informal ‑ we need to treat them with the respect they deserve. Nurses, nurse aides, lab technicians, and personal support workers didn’t get the respect and protections that were necessary during Covid, and in some cases they are still waiting for the personal protective equipment that they were promised during the height of the pandemic”, highlights Marie Clare Walker.

Commitment and accountability are the keys to progress. “We should remember something”, closes Baba Aye, “the impact of the pandemic would not have been this bad if steps that should have been taken that have been globally committed to, would have been taken. Including on funding of health, health employment, in particular. We are dangerously unprepared for the next pandemic. This means that we can’t be sure that the frontline health workers are safe. Governments need to get their priorities right of putting people above profit. It is within that context, the new paradigm of thinking that new approach for post‑Covid world that works for the many and not for the few that we can say yes, the health and safety of health workers becomes fully guaranteed.”

The interviews were conducted in July‑August 2020.

Rates of violence against health-care workers 16 % higher

Compared to other industries and sectors, health sector workers report the highest levels of violence globally. Healthcare workers, especially nursing staff, are also more likely to be exposed to offensive behaviours, including sexual harassment, than other professions. In the United States, rates of violence from clients against health-care workers were estimated to be 16 times higher than any other service profession.

And violence and assaults against health care workers, especially nurses, is on the rise:6 one in five registered nurses and nursing students reported being physically assaulted—and 50 % verbally abused within a year by a third-party i.e. patient, client or a member of public.

The same picture emerges in all countries that are reporting on the issue: in Switzerland, 95 % of nurses have experienced violence during their careers. Nurses in São Paulo, Brazil, reported that 74 % had experienced violence in their workplace8; 73 % of public hospital nurses in Lahore, Pakistan; 62 % in Gambia. In Taiwan, 56 % of nurses in acute psychiatric settings reported physical violence, and 82 % psychological violence. In Turkey, 60 % of nurses have been exposed to verbal and/or physical violence from patients, visitors or other health workers. In the EU, the health sector ranks highest among all sectors with regard to exposure to violence and harassment.

When thinking of the extent of the problem it is worth noting, that sexual harassment and violence are significantly underreported; many victims, bystanders and witnesses are afraid or reluctant to come forward or unsure about how to do so.

An utmost focus should be placed on occupational health and safety in preventing violence and harassment. Workplace safety is the foundation of decent work and equality, and all workers have the right to work in a safe environment without the threat of violence.

Photo credit: Barbasa

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Violence and harassment in the year of the nurse